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      What is the role of clinical tests and ultrasound in acetabular labral tear diagnostics?

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          Abstract

          Background and purpose An acetabular labral tear is a diagnostic challenge. Various clinical tests have been described, but little is known about their diagnostic sensitivity and specificity. We investigated the diagnostic validity of clinical tests and ultra-sound as compared with MR arthrography.

          Patients and methods We examined 18 patients (18 hips, 2 men, median age 43 (32–56) years) with impingement test, FABER test, resisted straight leg raise test, ultrasound, and MR arthrography. They had had previous periacetabular osteotomies due to symptomatic, acetabular dysplasia. All hips showed no or only slight signs of osteoarthritis (Tönnis grade 0–1).

          Results MR arthrography identified labral tears in 17 of the 18 hips. Ultrasound had a sensitivity of 94%, a positive predictive value of 94%, and was false negative in only 1 case compared to MR arthrography. The impingement test had the best diagnostic ability of the clinical tests, with a sensitivity of 59% and a specificity of 100%. The positive predictive value was 100% while the negative predictive value was 13%.

          Interpretation The impingement test is helpful in identifying acetabular labral tears. If this test is negative and if a labral tear is still suspected, ultrasound can reliably diagnose most tears of the acetabular labrum. MR arthrography is indicated in cases where ultrasound is negative, but the patient suffers continued, specific symptoms.

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          Most cited references22

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          Clinical presentation of patients with tears of the acetabular labrum.

          The clinical presentation of a labral tear of the acetabulum may be variable, and the diagnosis is often delayed. We sought to define the clinical characteristics associated with symptomatic acetabular labral tears by reviewing a group of patients who had an arthroscopically confirmed diagnosis. We retrospectively reviewed the records for sixty-six consecutive patients (sixty-six hips) who had a documented labral tear that had been confirmed with hip arthroscopy. We had prospectively recorded demographic factors, symptoms, physical examination findings, previous treatments, functional limitations, the manner of onset, the duration of symptoms until the diagnosis of the labral tear, other diagnoses offered by health-care providers, and other surgical procedures that these patients had undergone. Radiographic abnormalities and magnetic resonance arthrography findings were also recorded. The study group included forty-seven female patients (71%) and nineteen male patients (29%) with a mean age of thirty-eight years. The initial presentation was insidious in forty patients, was associated with a low-energy acute injury in twenty, and was associated with major trauma in six. Moderate to severe pain was reported by fifty-seven patients (86%), with groin pain predominating (sixty-one patients; 92%). Sixty patients (91%) had activity-related pain (p < 0.0001), and forty-seven patients (71%) had night pain (p = 0.0006). On examination, twenty-six patients (39%) had a limp, twenty-five (38%) had a positive Trendelenburg sign, and sixty-three (95%) had a positive impingement sign. The mean time from the onset of symptoms to the diagnosis of a labral tear was twenty-one months. A mean of 3.3 health-care providers had been seen by the patients prior to the definitive diagnosis. Surgery on another anatomic site had been recommended for eleven patients (17%), and four had undergone an unsuccessful operative procedure prior to the diagnosis of the labral tear. At an average of 16.4 months after hip arthroscopy, fifty-nine patients (89%) reported clinical improvement in comparison with the preoperative status. The clinical presentation of a patient who has a labral tear may vary, and the correct diagnosis may not be considered initially. In young, active patients with a predominant complaint of groin pain with or without a history of trauma, the diagnosis of a labral tear should be suspected and investigated as radiographs and the history may be nonspecific for this diagnosis. Diagnostic Level IV. See Instructions to Authors for a complete description of levels of evidence.
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            Acetabular labral tears rarely occur in the absence of bony abnormalities.

            We evaluated the percentage of patients with acetabular labral tears who have a structural hip abnormality detectable by conventional radiography. Records from our institution from 1996 through 2002 were reviewed to identify all patients with labral tears. Patients were excluded who had classic hip dysplasia, advanced osteoarthritis, or a history of pelvic or femoral osteotomy. The hip radiographs were evaluated for abnormalities of Tönnis angle, center-edge angle of Wiberg, acetabular version, femoral neck-shaft angle, congruency between the femoral head and acetabulum, anterior femoral head-neck offset, and presence of femoral head osteophytes. Twenty-seven of the 31 patients (87%) had at least one abnormal finding and 35% had more than one abnormality. Ten patients had a retroverted acetabulum, 16 had coxa valga, 11 had an abnormal femoral head-neck offset, and 14 had osteophytes on the femoral head. Four of 31 patients (13%) had no identifiable structural abnormalities. To our knowledge, this is the first study to document that the majority of patients with labral tears have a structural hip abnormality detectable with conventional radiographs. Familiarity with these structural abnormalities is important for early detection and accurate diagnosis, and may impact optimal treatment planning and prognosis.
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              Hip arthroscopy in the presence of dysplasia.

              Intra-articular pathology of the hip is often associated with dysplasia. The presence of dysplasia is often believed to be a harbinger of poor results for arthroscopy. The purpose of this study was to report the results of operative hip arthroscopy in conjunction with dysplastic disease of the hip. Prospective clinical case series. All patients undergoing hip arthroscopy are prospectively assessed with a modified Harris hip score performed preoperatively and postoperatively at 3, 12, 24, and 60 months. A minimum of 1-year follow-up has currently accumulated for 184 consecutive cases. The center edge (CE) angle of Wiberg is measured on the anteroposterior pelvis film and categorized as normal (> 25 degrees ), dysplastic (< 20 degrees ), or borderline dysplasia (20 degrees -25 degrees ). In this study, 48 patients were identified with either dysplasia (16) or borderline dysplasia (32). At an average of 27 months, 100% follow-up was noted. For the dysplastic group, the average preoperative score was 57 and postoperative score was 83. For borderline dysplasia, the average preoperative score was 50 and postoperative score was 77. Statistically, no difference was found between the 2 groups. Collectively, the average improvement was 27 points, with 79% (38 patients) of patients showing at least a 10-point improvement. The results of arthroscopy in the presence of dysplasia compare favorably with the general population previously reported. The response to treatment is probably dictated more by the nature of the intra-articular pathology rather than simply the presence or absence of radiographic evidence of dysplasia.
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                Author and article information

                Journal
                Acta Orthop
                ORT
                Acta Orthopaedica
                Informa Healthcare
                1745-3674
                1745-3682
                05 June 2009
                01 June 2009
                : 80
                : 3
                : 314-318
                Affiliations
                1simpleOrthopaedic Research Unit, Aarhus University Hospital CopenhagenDenmark
                2simpleDepartment of Radiology, Aarhus University Hospital AarhusDenmark
                3simpleDepartment of Orthopaedic Surgery, Hvidovre University Hospital CopenhagenDenmark
                Author notes
                Article
                SORT_A_399012_O
                10.3109/17453670902988402
                2823204
                19421915
                70218ce6-b27b-42b7-abf4-5c395a80cff6
                Copyright: © Nordic Orthopedic Federation

                This is an open-access article distributed under the terms of the Creative Commons Attribution Noncommercial License which permits any noncommercial use, distribution, and reproduction in any medium, provided the source is credited.

                History
                : 18 August 2008
                : 23 December 2008
                Categories
                Research Article

                Orthopedics
                Orthopedics

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